Free Form 115 - Kentucky

Form 115 Adopted 1/1/97

KENTUCKY DEPARTMENT OF WORKERS' CLAIMS SOCIAL SECURITY RELEASE FORM
I, _________________________________, having filed an Application for Resolution of Occupational Disease or Hearing Loss Claim for workers' compensation benefits, do hereby authorize the Social Security Administration to release or disclose the Department of Workers' Claims any information in their possession concerning my benefit or wage earnings.

Signed at _____________________, Kentucky, this the _______ day of ____________________, 20______.

__________________________ Plaintiff's Signature

__________________________ Social Security Number

_____________________________ Witness Signature